CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 3476 11192.50000 416472.6000 37.2100
Subtotal (Total Children Is Unduplicated) 3476 11192.50000 416472.6000 37.2100
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 5 5.000000 97.5500 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 5.000000 73.4000 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 5.000000 44.0500 8.8100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.000000 144.6000 28.9200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 5 5.000000 105.2000 21.0400
EXIT-EXIT-COS Exit 1 0.750000 37.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 37.000000 2775.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 7.500000 562.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 17.500000 1237.5000 70.7143
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 21.000000 1165.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 448 877.500000 65925.0000 75.1282
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 157 305.500000 22912.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 91 163.500000 12300.0000 75.2294
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 80 152.000000 11400.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 109 171.500000 13050.0000 76.0933
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 16 29.000000 2175.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 350 677.000000 37490.2500 55.3770
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 146 286.000000 15960.7500 55.8068
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 132 240.500000 18037.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 28.500000 2137.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 14 14.000000 719.7400 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 17 18.000000 873.9700 48.5539
PSTH-97161-PT EVAL LOW COMPLEXITY 11 11.000000 565.5100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 4.000000 143.9200 35.9800
SPCH-92521-EVAL OF SPEECH FLUENCY 47 50.000000 2570.5000 51.4100
SPCH-92521GT-EVAL OF SPEECH FLUENCY 6 6.000000 308.4600 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 11.000000 514.1000 46.7364
Subtotal (Total Children Is Unduplicated) 837 3168.750000 214384.2500 67.6558
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 6.000000 1419.1000 236.5167
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 49 47.250000 2362.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 265 234.000000 11700.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 19 12.250000 306.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 57 85.000000 4250.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 238 354.500000 17725.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 9 10.000000 500.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 29 39.750000 1987.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 9 8.750000 437.5000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 80 110.750000 5537.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 28 37.000000 1850.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 141 205.750000 10287.5000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 4.000000 100.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 3.000000 150.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 10.000000 500.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1098 8151.250000 407612.5000 50.0061
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 575 2966.000000 148300.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 349 2835.000000 42237.0000 14.8984
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1227 11471.00000 137652.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 400 1980.250000 139742.5400 70.5681
OCCT-97530GT-OT SESSION BY LICENSED OT 13 25.000000 1799.0000 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 84 350.500000 20097.8500 57.3405
OCCT-97530HMGT-OT SESSION BY OT ASST 2 3.000000 172.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 446 1848.250000 131382.3400 71.0847
PHY-97110GT-PT SESSION BY LICENSED PT 10 15.500000 1115.3800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 24 117.000000 6734.5200 57.5600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 7 25.500000 1467.7800 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 677 3853.000000 273488.3500 70.9806
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 43 115.250000 8293.3900 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 17.000000 979.2000 57.6000
Subtotal (Total Children Is Unduplicated) 2178 34941.50000 1380187.5000 39.5000
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Total 49302.750000 2011044.3500 40.7897
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Number of Children (Unduplicated) With at Least One Service 3837
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Center 10
Flag Claims Units Chgs Paid
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R 47 32.750000 1218.3000 0.0000
U 0 0.000000 0.0000 0.0000
B 8885 8002.000000 346828.6500 0.0000
P 11400 23601.000000 720098.7300 718701.8300
D 26 26.500000 865.1000 0.0000
S 64 82.000000 3042.8800 100.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
11899 17265.250000 927969.5900 0.0000
Other 404 293.250000 11021.1000 0.0000
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Total 32725 49302.750000 2011044.3500 718801.8300